[00:00:00] Christine Ko: Welcome back to SEE HEAR FEEL. Today, I'm excited to be speaking with Dr. Ian Katz. Dr. Ian Katz is a pathologist and leading expert in skin cancer at Southern Sun Pathology, Australia's largest dedicated skin cancer dermatopathology laboratory. Dr. Katz received his MBChB from the University of Cape Town in 1986, his BSc (Med) (Hon) from the same university in 1988, and has been a Fellow of the Royal College of Pathologists of Australasia since 1996. Dr. Katz has many interests, including mentoring healthcare entrepreneurs, building medical practices, and teaching about skin cancer and UV exposure. You can learn at driankatz.com and you can find him on Twitter @skincancerguru, and there'll be links to both of those in the show notes.
[00:00:48] Welcome to Ian.
[00:00:49] Ian Katz: Thanks for having me. I'm so excited to be talking to you.
[00:00:52] Christine Ko: I'm excited too. Could you share a personal story about yourself to help put your work and yourself in context for the listeners?
[00:00:59] Ian Katz: Sure. In Australia, most of the skin cancer work is actually done by family doctors and general practitioners because there is so much. Probably more than 80% of all skin cancers is diagnosed and treated by general practitioners. In the late nineties I helped a group of general practitioners set up their own lab. And I worked for them for a few years and a few afternoons a week, I had some spare time. I went into the clinics a few afternoons a week and was fascinated by the way they diagnosed and treated skin cancers. They taught me how to diagnose skin cancers clinically. They taught me how to use dermoscopy. They taught me how to do small biopsies, excisions, and small procedures in cryotherapy and things like that. I always was qualified as a family practitioner. So from then onwards, I got to know the importance of seeing your own patients, of understanding where the lesion is on the body, and how important it was to your diagnosis under the microscope of slides. After a few years, I actually went and set up my own skin cancer center where I saw my own patients. And that was probably around 2000. From about 2000 to almost 2022, the business grew and eventually we had about 30 skin cancer centers. That was my journey over about just over 25 years.
[00:02:13] Christine Ko: Thanks for sharing that. Since that's been your journey, what tips do you have, aside from really seeing the clinical lesion, on optimizing histopathologic diagnosis?
[00:02:25] Ian Katz: I had a bit of sinusitis a few years ago, and I went to see the ENT surgeon, and he sent me for an MRI scan of my sinuses. I went to see him after I'd done the MRI, and the first thing he did was he opened up his computer, and he looked at the MRI scan, even though the radiologist had reported the MRI scan. And that got me thinking like, why do most skin cancer doctors not look at their own? I think that it really is important for skin cancer doctors to understand and see their own digital pathology slides because there's so much subtlety in diagnosing skin cancers that it makes such a difference if you can see the slide.
[00:03:05] Christine Ko: How do you think you've developed your diagnostic eye over the years?
[00:03:11] Ian Katz: I've come to really realize that there's a lot of subtlety to what we see. A lot of the stuff we see is a continuous spectrum. Even if you think about from actinic keratosis to early invasive squamous cell carcinoma and to deeply invasives; there's very few specific cutoffs in these spectrums. Even dysplastic nevi to melanoma, in things like that. We make these artificial cutoffs in these spectrum of disease. It's so much more important to tell the doctors what to do next, to tell the patients what's next, rather than having a specific diagnosis. Of course, if you can give them a specific diagnosis, it's important. The other thing I've come to realize over the years, and it's something I teach my referring doctors immediately, is that the more I write, the less I know. In other words, the longer my report, the less certain is the diagnosis.
[00:03:59] Christine Ko: Yes. You've done a lot; you've created 30 plus skin cancer practices. What role do you think that emotional intelligence played in what you created and how you practice?
[00:04:12] Ian Katz: In terms of how I practice, I think there's a couple of things. First of all, I'm never afraid to be wrong. There's always pathologists that get upset if doctors phone and question them. I've always encouraged my doctors to phone and talk to me. If you think I've made a mistake, or you think I need to cut deeper levels, or you think I need to do immunoperoxidase, just give me a call and we'll do it. I think that's important to have that emotional intelligence to be able to know that you can be wrong.
[00:04:37] The other thing is when you get second opinions. Doctors who give second opinions will say, You're wrong. This is my opinion. I believe, and this is opinions I give and the opinions I get from others, you know, it's so much more subtle to say, I think this is a very difficult case. I think that's always good to say that when you give a second opinion. I can see why you said this, and although there are some features there, I personally think, though, that it could be something else. And I think there are very subtle emotional ways that you can put second opinions, which you're not putting people at risk or patients at risk or doctors at risk. Very nice way of putting things. And I think that's important to be able to do that. I think that's another important part of emotional intelligence when you practice.
[00:05:21] Christine Ko: Yes. How did you become comfortable with being wrong?
[00:05:25] Ian Katz: I think I've always been like that. You learn most of your pathology from your mistakes.
[00:05:30] Christine Ko: Yes, that's true for me, for sure.
[00:05:32] Ian Katz: Those cases in your life where you've made a mistake. I can remember a case from 15 years ago. I called an acral nevus and it was melanoma in situ. I can remember so distinctly in my head to this day, and I must have seen hundreds of thousands of cases in that time. And now every time I look at an acral nevus, I remember that case.
[00:05:52] I think that's so important. Those cases that touched you emotionally, that's embedded in your brain.
[00:05:57] Christine Ko: Yeah, exactly. I've read separately that what helps us remember is exactly what you just said. How emotionally invested we are in something really helps create memory.
[00:06:12] You said you learned the most from your mistakes. Are there other ways that you improve?
[00:06:16] Ian Katz: I do a lot of reading. I'm always reading journals. I'm following social media. I'm looking at cases online. I'm contributing to online discussion forums. I try and do exercise in the middle of the day. I find it makes such a big difference to how I can achieve during the day. I get a good amount of work done in the morning. I exercise, and I can really start my day again in the afternoon. I really enjoy that. That's part of, I think, continuously improving and being an effective pathologist. Absolutely.
[00:06:44] Christine Ko: Do you have any final thoughts?
[00:06:46] Ian Katz: ,, I'm collecting a data set for artificial intelligence. And I think what's quite interesting with this is how much other information we use when we're making a diagnosis. The multimodal diagnosis, the age of the patient, the sex, the clinical notes, the images; all that sort of stuff we use to make a diagnosis. As you've discussed before, the sequence that we do that in is probably quite important, and how difficult actually it is, and how subtle many of the things we do actually are. And as I said, there's a spectrum of things, and we can cut those things off very quickly in our brains in seconds. It's going to be very difficult to teach computers how subtle most of the stuff we do is. And that's something that I'm thinking about a lot lately.
[00:07:31] Christine Ko: Yeah, I think that computer needs a really good teacher.
[00:07:34] Ian Katz: Yeah. But even then it's it's gonna be very difficult. So I think what's gonna happen is that we're gonna have a computer that's going to diagnose BCCs like me, and there's gonna be a computer that diagnoses BCCs like you, and there's going to be really no consensus amongst the computers like there is no consensus among pathologists now. For example, the BCCs and the definitions of these subtypes of BCCs are nonexistent. Everyone diagnoses them differently.
[00:07:58] Christine Ko: Yeah. Subtype, yes. But just in general.
[00:08:01] Ian Katz: No, in general it's easier. Computers can diagnose BCCs very easily now. But, you've got to be able to put the subtype, the depth, the margins; all the other bits and pieces that take a bit of time.
[00:08:12] Christine Ko: Yeah. Artificial intelligence: it's going to be interesting to see what happens.
[00:08:18] Ian Katz: Yeah.
[00:08:19] Christine Ko: Thank you so much for spending time with me. I really appreciate hearing your thoughts and. Hearing about you a little bit more.
[00:08:28] Ian Katz: Thank you so much for having me. I really enjoyed it.